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Inspection on 16/01/08 for Sheldon Ridge Nursing Home

Also see our care home review for Sheldon Ridge Nursing Home for more information

This inspection was carried out on 16th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff team have a caring attitude and a good understanding of people`s needs. Wherever possible people are supported in making decisions and are encouraged to participate in activities outside the home. The staff have established good working relationships with other healthcare professionals, which makes sure that people`s healthcare needs are met. One GP felt that, "The staff are keen to seek advice and follow it". People are encouraged to maintain strong links with family and friends, and relatives are invited to take part in review meetings so that they can air their views and opinions of the service provided.

What has improved since the last inspection?

The recording and storage of medication has improved and this makes sure that people`s health needs are met safely. The environment continues to improve, there are still some areas requiring refurbishment, but overall the home looks and feels much better providing people with a comfortable home.

What the care home could do better:

The home provides some information, this is in the service user guide, but it is outdated and people do not appear to have their own copies. People have also not been supported to understand and agree important documentation that affects their rights living at the home. Person centred plans have been introduced but not completed. The care plans must be fully completed to make sure that care needs are not overlooked and that people are fully involved with their care. The storage problems must be resolved and signage intended for staff instruction removed from people`s bedroom walls. People`s privacy and dignity is compromised by staff instructions being displayed in their bedrooms. Health and safety concerns and the lack of a suitable staff call system mean that it is not always safe for people living and working at the home. There have been many changes of managers over the last two years. This affects the morale and support of staff, the continuity of care for people living at the home and their relatives and advocates. The present manager has been in post for just two weeks but says that this is a permanent placement. The manager must now apply for registration with us.

CARE HOME ADULTS 18-65 Sheldon Ridge Nursing Home 1/3 Bierley Lane Bradford West Yorkshire BD4 6AB Lead Inspector Linda Trenouth Key Unannounced Inspection 16th January 2008 13:00p Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sheldon Ridge Nursing Home Address 1/3 Bierley Lane Bradford West Yorkshire BD4 6AB 01274 688029 01274 684320 sueroberts@hotmail.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Brunel & Family Housing Association Limited Ms Susan Linda Roberts Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 2007 Brief Description of the Service: The home is a joint venture between Brunel Support Works and Bradford District Care Trust and is registered to provide long term nursing care for thirteen adults with challenging behaviour, physical needs, and learning disabilities. The home is situated in the village of Bierley and is close to local amenities and a main bus route into Bradford City centre. The home was originally two purpose built bungalows; an extension now links the bungalows. All bedrooms are single occupancy. Spacious communal areas include lounges and dining areas. The home has an attractive enclosed rear garden, with level access from the lounges. Fees for the service are currently £467:46 per week. Extra charges are made for hairdressing, aromatherapy, social activities, Personal toiletries and the running and maintenance of the mini bus. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We visited the service over two days for approximately 8 hours. The inspection also included gathering information and evidence before and after the visit to decide the overall judgement. The manager was available on the second day of the visit. We looked at the records and watched staff working. People who live at the home are not always able to communicate verbally due to their disabilities, therefore we spent time with them to see the relationships and interactions they had with each other and the staff. We also looked around the building. The main purpose of this inspection is to make sure that the service provides a good standard of care. We sent comment cards to one relative and a social and health care professional, to give them the opportunity to comment on the service. One comment card was returned. The manager of the home completed a self-assessment form called an AQAA, which is information we ask for every year and is used as part of the inspection process. The returned self-assessment documentation provides information about staffing and people who use the service. Feedback was given at the end of the inspection and requirements and recommendations made during this visit can be found at the end of the report. What the service does well: The staff team have a caring attitude and a good understanding of people’s needs. Wherever possible people are supported in making decisions and are encouraged to participate in activities outside the home. The staff have established good working relationships with other healthcare professionals, which makes sure that people’s healthcare needs are met. One GP felt that, “The staff are keen to seek advice and follow it”. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 6 People are encouraged to maintain strong links with family and friends, and relatives are invited to take part in review meetings so that they can air their views and opinions of the service provided. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People do not have the information they need to decide if the home is right for them. People are assessed before they move in to make sure their needs can be met. People are not properly supported to understand and agree to important documents, which inform them of their rights and responsibilities. EVIDENCE: The service user guide we saw is still being updated to include changes in the home. When this is completed copies must be given to people living at the home and to their relatives. People do not have updated information about the home and new admissions would not be able to make an informed choice about whether the home was right for them. No new people have been admitted to the home for about three years. The admission procedure for the home is thorough and staff say that new referrals are discussed at the allocation meetings. These meetings are held following a full assessment and make sure that a suitable placement is found. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 10 Staff say that when people are allocated, they visit the home over a period of time to help them and their relatives decide if the home is right for them. People have a contract but this has not been made clear to them, it is not signed and they may need some support to do this. It is important that when people have any important information or documents that they are properly supported by a relative or advocate to understand and agree to what is being asked of them. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People’s care and support needs are generally met but this is not reflected in the care plans. EVIDENCE: The home has introduced a new person centred care plan, which covers all areas of a person’s health and social care need. The format for the new care plans is good but not all areas have been completed by the staff. All areas need to be completed to make sure that people receive care in a way they prefer and their needs are not overlooked. Staff told me that relatives are involved in the care planning process and are invited to attend review meetings so they can air their views and opinions of the care provided. There are no copies of reviews however on people’s files. This means that staff do not have important information to update care plans and may overlook people’s care needs. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 12 Staff say that people are encouraged to make as many decisions and choices as possible within the limitations of their disability thereby improving their quality of life. This was not however reflected in the care planning. The section “ who would I like to help me in my intimate care needs” was not completed and the records do not show how people are involved in making decisions about their care. Risk assessments are included in the care plans and where areas of concern are identified action is taken to minimise risks without restricting people’s freedom of movement or choice. Staff observed at the visit are clearly able to interpret people’s different communication and encourage people to make decisions in their daily lives. Staff we spoke to show a good understanding of people’s needs and are able to give good examples of how people’s individual care needs are met. This is important to make sure that people’s individual needs are not overlooked and choices are met. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 16 and 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People enjoy an active and varied lifestyle and participate in a wide range of community activities. EVIDENCE: The home has an activities co-ordinator who is responsible for arranging activities and outings for everyone. Care staff also said that more emphasis and time is now being placed on encouraging people to develop daily living skills and providing activities rather than having a very rigid daily routine. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 14 Staff clearly had a good knowledge of people’s hobbies and interests and supported people to engage in a variety of activities. Staff say that they are always looking for interesting and different activities that people may enjoy. The multi sensory room is out of action and being used for storage. The staff say that some sensory equipment is being refurbished but were unclear when this room could be used again. Some people in the home benefit greatly from this resource and the opportunity for this type of activity is significantly reduced. The home has two mini buses and these are used every day. This means that people can regularly access places of interest in the local and wider community. Staff say that people are supported to have regular contact with their family and friends. A full time cook is now employed at the home to provide people with a varied and balanced diet. The cook says he aware of people’s dietary needs and personal choices. This is important to make sure that everyone’s needs and choices are met. The meal prepared looked appetising and well presented and the mealtime observed was relaxed and unhurried. People who need assistance to eat their meals were helped in a sensitive manner and individuals ate at their own pace. This is important to make sure that people have a positive experience at meal times and their needs are supported. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People’s personal and healthcare needs are met. EVIDENCE: People’s health care needs are well recorded. Staff show a good understanding of individual health needs and feel it is important to promote people’s well being. Records showed GP (General Practioner) referrals and specialist involvement in maintaining health care. During the visit staff followed through health concerns of one individual to make sure that their health needs are fully met. The manager confirmed that people are supported by the staff team in accessing healthcare services, and accompany them on visits to see their GP or outpatient appointments. One GP commented, “ I think on the whole they do a good job for a challenging client group.” Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 16 The input of other healthcare workers is recorded and shows that staff are seeking professional help if they have any concerns. One comment card from a GP said, “The staff are keen to seek advice and follow it” Due to the level of ability of people living at the home, staff support everyone to take their medication. Each person has a clear record to guide staff when to administer medication if they are in pain or become distressed. This is to make sure that staff are consistent and only give medication when necessary. We saw that there was good stock control and that medication is safely stored. The records are completed appropriately to make sure that any mistakes are reduced and people’s health needs are supported. During conversations with staff it was evident that they had a good understanding of the individual needs of the people. There is a key worker system in place, which allows staff to focus on individuals and develop relationships with relatives and other professionals. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Staff have completed adult protection training to make sure that people are safe from harm. EVIDENCE: Adult protection policies and procedures are in place and staff have training in adult protection awareness. The manager keeps a training audit to make sure that this training is up to date for everyone. This is to make sure that people are protected from harm. People are unable to manage their own money. Where relatives are unable to manage people’s personal money the manager and staff take on this responsibility. People have their own bank account. Their personal allowance is held in safe keeping in the home. The staff complete financial documents to show how the money is managed and show any transactions that have occurred. The manager and staff monitor this to make sure that people are safe from any financial abuse. There is a complaints record but the availability of the complaints procedure is limited due to the “service user guide,” not being completed and distributed. People can have information of the Trust’s complaints procedure upon request. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People live in a comfortable, homely environment but the heating system needs to be reviewed. EVIDENCE: The home is situated in the village of Bierley and is close to local amenities and on a main bus route. The home was originally two purpose built bungalows; an extension has linked the bungalows, and created more communal space. Some bedrooms and a shower room still require refurbishing and it is anticipated this work will start in the near future. The home however continues to improve, providing people with a better quality of environment. The style of locks on bedroom doors have been changed to make sure that people can have privacy but be supported by staff if needed. At the present time no one uses a key to their bedroom door but this is always an option. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 19 The communal areas including lounges and dining rooms have recently been decorated and carpets replaced with new laminate wood effect flooring, which has eliminated any odour problems. New furniture has been provided for the lounges and pictures fitted to generally brighten up the rooms. This is important to give the home a more comfortable appearance. Bathrooms and toilet facilities are located throughout the building and there is an assisted bath available for more dependent people. There is also a shower room although funding has been requested to refurbish this area to make it easier for people to use. Storage seems to be a problem in the home, bathrooms are being used to store dehumidifiers, Christmas decorations and other items. Appropriate safe storage must be found for these items and staff must make sure that bathrooms are comfortable and free from hazards. Freestanding electric heaters are being used throughout the home. Staff say that there has been a problem with heating in some areas. Advice must be sought from the fire officer regarding these heaters and risk assessments completed. The heating system also needs to be reviewed to make sure that it is adequate for the home. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People are supported by a trained staff team however recruitment procedures need to be improved to make sure that people living at the home are protected. EVIDENCE: At present the home has no job vacancies in either nursing or care staff. Recruitment for a weekend cook and activities coordinator is underway and hopefully they will be in post soon. This will make sure that an effective staff team supports people in the home. The recruitment documents for staff are not all available. Application forms and evidence of an up to date CRB are missing from staff files, this has been a concern at previous inspections. This may mean that people are put at risk by employing staff who are not safe to work at the home. Bradford District Health Trust also transfers staff from home to home. Recently a member of staff has transferred but there is no personnel and supervision information. This makes it difficult for the manager to support this member of Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 21 staff effectively and people cannot be sure that this person is safe to work at the home. There is a staff-training audit, which shows staff are always updating their training. If people need additional training this is identified through formal staff supervision and appraisal. Staff say that they are encouraged to undertake training and some have recently completed updates in moving and handling and adult protection. At present nine out of the eighteen care staff have achieved a National Vocational Qualification (NVQ) at level two and above. This is to make sure that skilled and competent staff care for people at the home. Staff say that there have been a lot of management changes at the home. They say that have they have had regular supervision from their previous manager. Despite the management changes staff felt that they worked well as a team and that the level of care they provide is good. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Management of the home is inconsistent due to continual changes of manager, which is not in the best interests of people living there. EVIDENCE: Brunel and Family Housing are responsible for the overall management of the service. They do not however manage the care staff at the home. The staff are provided by Bradford District Care Trust. The present manager has been in post for two weeks, the home has had four different managers in the last two years. This cannot help build a consistent leadership for staff at the home and effects morale for everyone. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 23 The present manager is experienced and has a good track record in managing care. It is difficult however to assess his leadership and running of this home after such a short period. The manager says that his post is permanent at the home and therefore is required to be registered with us. The service has failed to register a manager in the last two years. The manager is becoming familiar with the home and has begun supervision and auditing staff immediate training needs. There are some concerns about how well staff monitor health and safety in the home. The water temperatures records are inconsistent and temperatures are high but appropriate action does not appear to have been taken. There is still no call system in the home. This means that staff cannot summon assistance when required. Staff at times are shouting across the home to ask for help. The manager says that there is a portable pager system available for night staff but cannot confirm when a permanent call system will be fitted in the home. This may mean that people are put at risk. To ensure the health and safety of the service users and staff it is important that this matter is resolved as soon as possible. The previous manager had held a relatives meeting and although it was poorly attended there are plans to arrange further meetings as part of the quality assurance monitoring process. The involvement of relatives and advocates is important and work has begun to involve carers and to keep them informed of any changes planned. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 x 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 x 28 x 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 3 x x 2 2 Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 25 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 5 Requirement The service user guide must be updated to reflect changes in the home. This is to make sure that everyone has the right information about the home. Everyone must be supported to understand and agree important documentation that affects their rights living at the home. The person centred plans must be fully completed to make sure that care needs are not overlooked and that people are fully involved with their care. A schedule of refurbishment works for the bedrooms and shower rooms must be provided. Previous timescale 30/06/07 not met. An effective nurse call alarm system must be provided. Previous timescales 30/06/07 not met. All staff recruitment and supervision records must be held in the home. The records must provide evidence that all the required appropriate checks have been completed and support has been given. DS0000019895.V357485.R01.S.doc Timescale for action 30/04/08 2 YA5 5 30/04/08 3 YA6 15 30/04/08 4 YA24 23 30/04/08 5 YA29 23 30/06/08 6 YA34 17 30/04/08 Sheldon Ridge Nursing Home Version 5.2 Page 26 7 YA37 8 Previous timescales 30/04/06, 01/10/06 and 01/03/07 not met. A Registered Manager must be appointed. Previous timescales 01/08/06 and 01/03/07 30/06/07 not met. 30/04/08 8 YA42 23 The use of free standing heaters 30/04/08 must be risk assessed to make sure that people are safe and not at risk of harm. The heating system must be sufficient to keep all areas of the home warm enough for the people who live there. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA42 YA42 Good Practice Recommendations Quality assurance monitoring systems must be maintained. Water temperature checks must be maintained regularly to make sure that everyone is safe. Storage throughout the home must be reviewed. People’s bedrooms, communal areas, and bathrooms must not be used for storage. This is to make sure that all areas of the home are free from hazards and that people can use their home safely. Sheldon Ridge Nursing Home DS0000019895.V357485.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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